CMS Pub. 100-04, ch. 1, § 130.5

Several conditions can cause the claim for a HH period of care (Type of Bill 032x) to be

adjusted. Claims may be cancelled (TOB 0328) by HHAs if a mistake is made in billing.

In these cases, the period of care will be cancelled in CWF as well. Adjustment claims

(TOB 0327) may also be used to change information on a previously submitted claim,

which may also change payment.

A home health agency submits a corrected claim if any of the following apply (the list is

not exhaustive):

• A change in provider number;

• A change in visits (decrease or increase);

• A change in diagnosis code or other claim elements affecting the determination of

the HIPPS code used for payment; or

• A change in the patient status code affecting payment of the claim or the ability of

other providers subject to HH consolidated billing to be paid for covered services.

Diagnosis codes on HH claims reflect the patient’s condition as of the start of a period of

care (the claim From date). Errors in diagnosis codes which applied on the From date of

a given period of care may be corrected with an adjustment claim. The HHA reports

condition code D4 on the adjustment claim. Diagnosis codes that reflect a change in the

patient’s condition during a period of care should be reflected on the claim for the next

period.

An HHA may submit a claim with patient status code 30 (still patient) at the end of a

period of care on the expectation that additional HH visits will be provided in the next

period of care. Some intervening event may prevent the delivery of additional visits and

the beneficiary is subsequently discharged. In this situation, the HHA shall submit an

adjustment claim to correct the patient status code to reflect the discharge on their claim,

since patient status code 30 may prevent billing of services subject to HH consolidated

billing during the last days of the period of care. The HHA reports condition code E0

(zero) on the adjustment claim.

130.6 - Adjustments to Reprocess Certain Claims Denied Due to an

Open Common Working File (CWF) Medicare Secondary Payer (MSP)

Group Health Plan (GHP) Record Where the GHP Record Was

Subsequently Deleted or Terminated

(Rev. 4201, Issued: 01-18-19, Effective: 02-19-19, Implementation: 02-19-19)

The term Medicare beneficiary identifier (Mbi) is a general term describing a

beneficiary’s Medicare identification number. For purposes of this manual, Medicare

beneficiary identifier references both the Health Insurance Claim Number (HICN) and

the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition

period and after for certain business areas that will continue to use the HICN as part of

their processes.

Group Health Plan (GHP) Medicare Secondary Payer claims were not reprocessed

automatically in situations where Medicare becomes the primary payer after an MSP

GHP record was deleted, or when an MSP GHP record was terminated, after claims were

processed subject to the CWF record. It was the responsibility of the beneficiary,

provider, physician or other supplier to contact the Medicare contractor and request the

denied claims be reopened when reopening was permitted. This was a burden on the

beneficiary, physician, or other supplier. This instruction directs CWF to implement an

automated process to reopen certain MSP claims when MSP GHP records were 1)

deleted, or 2) under some circumstances, certain MSP GHP records were terminated and

claims were denied (rejected for Part A claims) due to MSP or Medicare made a

secondary payment before the termination date was accreted.

The COBC currently identifies, deletes, and terminates MSP GHP records on the CWF

when appropriate. The 1-800 Medicare also applies simple terminations to MSP GHP

working aged records only. Upon deletion of an MSP record, or where a termination

dated added to an MSP GHP (MSP Codes 12, 13, 43) record, this instruction directs the

CWF to search the claims history for claims, with dates of service within 180 days of the

deletion date, or the date the termination date was applied, which were processed for

secondary payment or were denied because of the MSP edit as set forth in 42 CFR 405,

subpart G, H and I. The Shared Systems shall reopen these claims, as necessary,

including locating any claims billed to Medicare as primary, or secondary, and denied

(rejected for Part A claims) on the basis of the subsequently deleted CWF MSP GHP

record. Claims with added termination dates shall be reopened no earlier than the

termination date applied to CWF.

The CWF shall generate an unsolicited response “W” and send this response with the 24

and 10 trailers containing the identifying information regarding any such claims found to

the shared system. The unsolicited response shall include all the necessary information to

identify the claim(s), including the Document Control Number/Internal Control

Number/Claim Control number, Medicare beneficiary identifier, beneficiary name, and

date(s) of service. The CWF electronically transmits this unsolicited response to the

claims processing contractor(s) that originally processed the claim(s) or send the claim to

the MAC contractor that assumed the workload for the original legacy contractor that

processed the claim. The previously denied claim(s) (rejected for Part A) is not to be

canceled and remains on the CWF claims history pending subsequent adjustment as

warranted.

Upon receipt of the unsolicited response, the shared system software reads the claim

information in the trailer for each claim and performs an automated reopening to each

claim. The claim(s) must be reopened and adjusted as warranted for all non-reimbursed/claim denials (part A rejections)/ where Medicare paid secondary or

terminations that were based upon the MSP GHP record that was just deleted or

terminated. The MSP unsolicited responses are reported with the current MSP responses

when COB deletes an MSP record a “03” will be received. The shared systems release

the adjusted claims. Adjustments are subject to all applicable edits as the original claim(s)

and sent to the CWF so that the claim(s) on the CWF history are replaced with the

adjusted claim(s) records.

The automated MSP GHP reprocessing requirement allows CWF to alert the shared

system when a MSP GHP record is deleted or a termination date added for specific

beneficiaries. The shared systems and Medicare Contractors receive an IUR transaction

response from CWF alerting the system to reprocess certain MSP GHP claims where the

open GHP record was deleted /terminated by the Coordination of Benefits Contractor

(COBC) or 1-800-Medicare. This unsolicited transaction is sent to the contractors on

record at CWF who had claim history for the associated beneficiary within the 180 day

period. The CWF system is already programmed to send an updated MSP transaction

(HUSC transaction) any time a change is made to an MSP record and this process does

not change.